Haemorrhage Shock Transfusion

8/13/2019 Haemorrhage Shock Transfusion

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HAEMORRHAGE&BLOOD TRANSFUSION

By;Col Abrar Hussain Zaidi


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INTRODUCTION


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INTRODUCTIONDefinitions

Haemorrhage--bleedingEscape of blood from a blood-vessel

Exsanguination- total loss of blood

Desanguination- major loss of blood

[Encyclopedia Britannica]


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INTRODUCTIONSubjects importance

Haemorrhage is one of the basic problemsand considerations in surgery

From-trivial trauma or major abdominal organinjuries-to- congenital and acquired

coagulation disorders

A wide spectrum of problems involveshaemorrhage

Transfusion of blood is the main remedy


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INTRODUCTIONClinical Situation Trauma /accidents General operatiove interventions

Gynaecological procedures Congenital coagulation disorders Acquired coagulation disorders

DicAnticoagulantsFulminent sepsisMof Common surgical conditions pres w bleed

Intracranial haemorrhages/cvaUpper git bleed/haemetemesis and melenaBleeding haeorrhoidsChronic woundsAnal fissuresAneurysms


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INTRODUCTIONPhysiology

BODYS SYSTEM OF HOMEOSTSIS

INTEGRITY OF EVERY SYSTEM

ANATOMICAL

FUNCTIONAL


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INTRODUCTIONClaude ernards concepts

French physiologist Claude Bernard (1813-1878), the founder of experimentalphysiology and experimental pharmacology.

Bernard believed that the body hasmechanisms by which it seeks to maintain a

stable internal environment despite changesin the external environment- Homeostasis[ 1851]


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INTRODUCTIONWhat Prevents HaemorrhageNATURAL BARRIERS AGAINST HAEMORRHAGE

Integrity of vascular wall Coagulation system


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INTRODUCTIONodys response tohaemorrhage/injuryAttempts to repair the loss & restorenormality

There are several interrelated stagesLocal response / Gen responseAims at:

wall repair Restoration of volume loss


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INTRODUCTIONodys response tohaemorrhage/injuryVirchow 1856 famous triad:

1. Stasis 2. Endothelial damage 3. Hypercoaguable stateslocal Vasoconstriction Platelet aggregation and plug formation Coagulation leading to Fibrin formation Intrinsic &Extrinsic PathsGeneral Compartmental Volume movement


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PATHOLOGICAL BASIS OFHAEMORRHAGE

BLEEDING CAN RESULT DUE TO:

LOSS OF INTEGRITY OF WALL

TRAUMA/OERATIONS

COAGULATION DEFECTS

CONGENITAL - H.PH

AQUIRED -DIC


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ETIOLOGY OF HAEMORRHAGECAUSES OF HAEMORRHAGE

INJURY /TRAUMA[+ operations]-It commonly results intearing or cutting of a blood-vessel-integrity ofwall breached - Trivial OR Major

DISEASES that alter coagulationCongenital platelet defects

Coagulation factor defectsAcquiredscurvySepsisDIC


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TYPES OF HAEMORRHAGE AMOUNT OF LOSS --MINOR/MAJOR

ACUTE/CHRONIC

ARTERIAL/VENOUS/CAPILLARY/MIXED LOCALIZED/DIFFUSE

EXTERNAL/ INTERNAL

OVERT/OCCULT


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TYPES OF HAEMORRHAGEBleeding from an artery is of a bright red colour, andescapes from the end of the vessel nearest the heart in jets

synchronous with the heart's beat

Bleeding from a vein is of a darker colour; the flow issteady, the bleeding is from the distal end of the vessel .

Capillary bleeding is a general oozing from a raw surface .


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TYPES OF HAEMORRHAGESPECIFIC TYPES Bruise or ecchymosis .

Extravasation of blood /pouring out of bloodinto the areolar tissues, which become boggy Haematemesis and melena Haemoptysis . Haematuria Epistaxis


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TYPES OF HAEMORRHAGECLASSIFICATION OF SURGICAL HAEMORRHAGEHaemorrhage has been classified as

1-Primary, occurring at the time of the injury

2-Reactionary, or within twenty-four hours of theaccident, during the stage of reaction

3-Secondary, occurring at a later period and

caused by faulty application of a ligature orseptic condition of the wound . In severehaemorrhage, as from the division of a largeartery, the patient may collapse and deathensue from syncope .


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Hemorrhage -four classesAmericanCollege of Surgeons' Advanced Trauma Life Support (ATLS)

Class I Hemorrhage involves up to 15 of blood volume.There is typically no change in vital signs and fluidresuscitation is not usually necessary.

Class II Hemorrhage involves 15-30 of total bloodvolume. A patient is often tachycardic (rapid heart beat)with a narrowing of the difference between the systolicand diastolic blood pressures. The body attempts tocompensate with peripheral vasoconstriction. Skin maystart to look pale and be cool to the touch. The patientmay exhibit slight changes in behavior. Volumeresuscitation with crystalloids (Saline solution or LactatedRinger's solution) is all that is typically required. Bloodtransfusion is not typically required.


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Hemorrhage -four classes AmericanCollege of Surgeons' Advanced Trauma Life Support (ATLS

Class III Hemorrhageinvolves loss of 30-40 of circulating bloodvolume.blood pressure drops, the heart rateincreases, peripheral perfusion (shock), such ascapillary refill worsens, and the mental statusworsens. Fluid resuscitation with crystalloid andblood transfusion are usually necessary.

Class IV Hemorrhage involves loss of >40 ofcirculating blood volume. The limit of the body'scompensation is reached and aggressiveresuscitation is required to prevent death.


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NBFit Individualsmay have more effective compensatorymechanisms before experiencing cardiovascular collapse.

These patients may look deceptively stable, with minimalderangements in vital signs, while having poor peripheralperfusion.Elderly patients or those with chronic medical conditionsmay have less toleranceto blood loss, less ability tocompensate, and may take medications such asbetablockers that can potentially blunt the cardiovascularresponse. Care must be taken in the assessment of thesepatients.


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EFFECTS OF HAEMORRHAGEDepend upon following:

Acute loss vs Chronic loss

The amount of loss

The compensatory mechanisms

General state of health


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EFFECTS OF HAEMORRHAGEDepends upon the amount of blood lossStages of HypovolemiaStage 1 Up to 15% blood volume loss (750mls) Compensated by constriction of vascular bed Blood pressure maintained Normal respiratory rate Pallor of the skin Slight anxiety


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EFFECTS OF HAEMORRHAGEStage 2 15-30% blood volume loss (750 - 1500mls) Cardiac output cannot be maintained by arterial

constriction Tachycardia >100bpm Increased respiratory rate Blood pressure maintained Increased diastolic pressure Narrow pulse pressure Sweating from sympathetic stimulation Mildly anxious/Restless


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EFFECTS OF HAEMORRHAGEStage 3 30-40% blood volume loss (1500 - 2000mls) Systolic BP falls to 100mmHg or less

Classic signs of hypovolemic shock Marked tachycardia >120 bpm Marked tachypnoea >30 bpm Decreased systolic pressure Alteration in mental status (Anxiety, Agitation) Sweating with cool, pale skin


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EFFECTS OF HAEMORRHAGEStage 4-----Shock Loss greater than 40% (>2000mls) Extreme tachycardia with weak pulse Pronounced tachypnoea Significantly decreased systolic blood

pressure of 70 mmHg or less Decreased level of consciousness Skin is sweaty, cool, and extremely pale

(moribund)


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MANAGEMENT OF HAEMORRHAGE Prevention Precautions during surgery Operative method of control of

haemorrhage Blood Transfusion


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SURGICAL HAEMOSTASISNATURAL OR ARTIFICIAL

Natural CONTROLE/arrest of haemorrhage arisesfrom ;

(1) the coagulation of the blood itself,(2) the diminution of the heart's action as in

fainting,

(3) changes taking place in the cut vesselcausing its retraction and contraction .


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SURGICAL HAEMOSTASISEXTERNAL HAEMORRHAGE /WOUNDSThe surgical procedure for the treatment of anopen wound is-

(1) arrest of haemorrhage;(2) cleansing of the wound and removal of anyforeign bodies;

(3) careful apposition of its edges and surfacessutures of aseptic silk or catgut, the surfaces bycarefully applied pressure;

(4) free drainage, if necessary, to preventaccumulation either of blood or serous effusion;

(S) avoidance of sepsis;(6) perfect rest of the part .


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SURGICAL HAEMOSTASISSurgical treatment of haemorrhageminor means of arresting bleeding are:cold, which is most valuable in general oozing andlocal extravasations;very hot water, 130 to 16o F., a powerfulhaemostatic; position, such as elevation of the limb,valuable in bleeding from the extremities;

styptics or astringents, applied locally, asperchloride of iron, tannic acid and others, the mostvaluable being suprarenal extract .


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SURGICAL HAEMOSTASISSurgical treatment of haemorrhage

DIRECT PRESSUREIn small blood vessels pressure will besufficient to arrest.haemorrhage permanently .

LIGATUREIn large vessels with a reef-knotmain artery of the limb exposed by dissectionat the most accessible point .


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SURGICAL HAEMOSTASISSurgical treatment of haemorrhage

Diathermy Sutures

Harmonic devices


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TRANSFUSION MANAGEMENT Early recognition of significant blood loss it is commoner to see patients who have been under-

transfused than over-transfused. I t is essential to pay attention to and act on

recordings of pulse rate and blood pressure. In a fit patient without cardiac disease, persistent

tachycardia even if blood pressure is maintained is likely to indicate continuing blood loss.


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SURGICAL HAEMOSTASISINTERNAL HAEMORRHAGE /WOUNDSCauses Penetrating wounds

chest,abdomen,neck,limbs Upper GI haemorrhage

BleedingUlcers

Lower GI haemorrhageDiverticulosisHaemorrhoids

Carcinomas


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SURGICAL HAEMOSTASISINTERNAL HAEMORRHAGE /WOUNDSPrinciples of management

Teat the primary cause

Avoid irrevercible shock

Flid electrolytes

Blood and blood produvts


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Types of bleeding

A subconjunctival hemorrhage is a common and relativelyminor post-LASIK complication.

The endoscopic image of linitis plastica, a type of stomach

cancer leading to a leather bottle-like appearance withblood coming out of it.


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RESPONSE IN INJURYVasoconstriction is mediated through intrinsic mechanisms andvarious vasoactive agents (thromboxane A2 and serotonin)released during platelet aggregation.COAGULATION SYSTEM Virchow in 1856 described the famous triad: 1. Stasis 2. Endothelial damage 3. Hypercoaguable states

The coagulation system is based on the coagulationcascade. The end points of this cascade include theformation of thrombin and fibrin. Throughout this system there can be defects in themultiple enzymes or extrinsic factors contributing to itsdysfunction.Fibrinolysis

There is a delicate balance between formation and lysis of


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Table 3.2. Coagulation cascadeIntrinsic Contact Tissue factor + VIIa XIa + VIII

Common Pathway Xa + V IIa Clot


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Gastrointestinal haemorrhage: haematemesis and melaena

Haematemesis: vomiting fresh red blood.

Coffee-ground vomiting: vomiting of altered black blood.

Melaena: the passage of black tarry stools.

Bleeding may be from oesophageal varices or from other sites(non-variceal bleeding).

Acute upper gastrointestinal (GI) bleeding affects 50 to 150 per100,000 of the population each year and accounts for asubstantial proportion of all blood used in UK hospitals. In theUK in 1995, mortality was reported to be 11% in patientsadmitted to hospital because of bleeding and 33% in those whodeveloped gastrointestinal bleeding while hospitalised for otherreasons. In the west of Scotland in 1997, the corresponding

fi 8 2% d 43% M t d th i ld l ti t

Haemorrhage Shock Transfusion

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